Provider Demographics
NPI:1073739561
Name:COASTAL REHABILITATION INC
Entity Type:Organization
Organization Name:COASTAL REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLYSTONE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:252-338-2114
Mailing Address - Street 1:101 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27969-3361
Mailing Address - Country:US
Mailing Address - Phone:252-338-2114
Mailing Address - Fax:252-338-2115
Practice Address - Street 1:501 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27938
Practice Address - Country:US
Practice Address - Phone:252-357-1011
Practice Address - Fax:252-357-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7700350Medicaid
0002WOtherBCBS FACILITY
07763OtherBCBS
NC7200037Medicaid
0002WOtherBCBS FACILITY
NC7200037Medicaid
NC7200037Medicaid
=========008OtherTRICARE